GW1-2022-05585_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
FranlCle L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
62,74 ft. 94,99 ft.
3002-A 252 ft. fL
NC Well Contractor Certification Number r-15.'OUTER CASING(for multi-casedwells)OR LINER(if a 'lit able
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAI.
0 ft. 47 ft' 6114 I" SDR21 PVC
Company Name r16.1NNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 21-320 FROM TO DIAMETER I THICKNESS MATERIAI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
'17 SCREEN
Water Supply Well:
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) ,18.GROUT
'Irrigation ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour 15 501b Bags
Monitoring ORecovery
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL`PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStornwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soivrock type, rain size,etc.)
0 ft' 3 t' Brown Clay
4.Date Well(s)Completed:4-11-2022 Well ID# 3 ft' 12 ft. Orange Clay
5a.Well Location: 12 ft. 39 ft. Brown Sand/Gravel
Saverio Montecalvo 39 ft' 400 ft' Granite
Facility/Owner Name Facility ID#(if applicable) ft. fL
7415 Sims Rd.Waxhaw 28173 ft. ft. �" 0 ,
Physical Address.City.and Zip ft. ft.
Union 05-117-003A 21:REMARKS
County Parcel Identification No.(PIN)
nlorin I'royrtg )n i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34.53.560 N 80.44.576 W
4-28-2022
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this for i.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 24oZ completion of well construction to�0e county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016